I talked about medical surge a month or two ago in preparation for a grandiose goal – spearheading a community wide pandemic surge planning process in conjunction with county public health. Since I’m a disaster geek at heart, I also have a secret agenda. Under the masquerade of pandemic planning, I hope to build the structure needed for any type of medical surge.

Step one is convincing my medical community of the need for both individual business and community wide pandemic plans. I shared the following thoughts during a recent kick-off meeting for our local stakeholders (about 60 in attendance), and afterwards, many seemed inspired to act (of course, whether they actually do anything remains to be seen). Perhaps I can convince you as well!

Influenza – the Poster Child for Pandemic Planning

Influenza is our best model for pandemic planning. The “powers that be” play with influenza plans every year – monitoring activity and strains, predicting the “best” vaccine (and convincing people to get it), teaching about prevention, and worrying about pandemics. There is even a flu.gov site to share some of the massive amount of influenza information available. H1N1 actually gave us a chance to “exercise” pandemic plans, with both successes and failures. Best of all, influenza is familiar (who hasn’t spent a few miserable days in bed with flu?), and therefore represents a threat that everyone can grasp (as opposed to a horrific earthquake that only happens every several hundred years).

Pandemic Predictions – What Do They Really Mean?

Numbers – what do they really mean? Photo by Mervyn Chua.

So how might pandemic flu differ from seasonal flu? What’s the fuss about? It’s easy to find basic numbers. Seasonal influenza in the United States causes about 36,000 deaths and 220,000 hospitalizations a year. A significant pandemic flu may cause 89,000-207,000 deaths and 314,000-734,000 hospitalizations.

I don’t know about you, but those numbers mean nothing to me. Even with seasonal flu, they are just too big. In addition, national statistics don’t help me understand the potential impact on my community. So I’ve played some number games to help translate statistics into concepts I hope anyone can grasp. I won’t guarantee my calculations, but I believe they are reasonable estimates. (If anyone has more accurate data, please share!)

A significant pandemic influenza wave will most likely last 4-12 weeks, with 53,000 – 171,000 potential excess deaths occurring in this short time period (the difference between seasonal and pandemic numbers). If you compare this to normal US death rates from all causes, these excess deaths could represent a sudden 25-40% increase in total deaths – quite a surge in morgue and funeral home demand!

Pandemic Effects on Hospitals

For hospitals, I compared excess pandemic hospitalizations to normal rates. I came up with a 5-10% increase in hospital admissions for the same 4-12 weeks. However, the most important number is not admissions – it’s the number of filled hospital beds (hospital census). Census is determined not only by admissions, but also by how many days patients stay in the hospital. Seasonal influenza patients already average about one day longer than other hospital patients – pandemic length of stay will surely be at least this long. The real increase in hospitalized patients during pandemic on any given day might be twice the 5-10% mentioned above.

Intensive CarePhoto by JSade

Influenza complications often include pneumonia and respiratory failure, which means increased use of intensive care, ventilators and other specialized equipment. In the H1N1 pandemic, some hospitals ran out of ventilators. Does your hospital have 10% more ventilators lying around waiting for a pandemic?

Of course, like any medical surge, both sick and worried well may flock to emergency rooms, particularly when uninsured or lacking a primary physician (or if their regular clinic can’t handle the demand). When overrun, emergency rooms may choose to refuse care to those with lower medical needs, or even limit public access. Where will those patients go?

Pediatrics is another (frequently ignored) problem for pandemic hospital planning. In this age of specialized pediatric hospitals, many community hospitals no longer have expertise or equipment needed to care for sick children. In pandemic influenza (unlike seasonal flu), many healthy children may become ill, quickly exceeding pediatric hospital capacity. How will local hospitals quickly regain pediatric capability, perhaps at an intensive care level?

Outpatient Care – The Bulk of the Burden

Let’s not forget outpatient care. Primary care and urgent care clinics actually bear the greatest burden in pandemic – only a small percentage of pandemic patients require hospitalization, but many need to see a doctor. Physician visits may increase by 8 – 23% just for pandemic related problems, not to mention increased clinic phone calls, prophylactic treatments such as vaccines and antivirals, and ongoing care for other medical problems, some of which may worsen from the stress of pandemic.

Some areas of specialty care may swing the opposite direction in pandemic. Many patients will postpone elective surgeries and non-urgent problems (such as ophthalmology and dermatology) until the pandemic calms down, particularly if social distancing is recommended by public health. Although helpful from an infection control and overall surge standpoint, disappearance of patients for weeks could be financially disastrous for a specialty clinic. Could they play a new and different role during surge?

Other Areas of Healthcare – Few are Spared

Chronically homebound patients may actually suffer less pandemic influenza because of lack of exposure, but caregiver illness may leave these patients without assistance. In addition, if quarantine is recommended, a glut of newly “homebound” ill may arise. Hospice and home health providers could help with these needs, including provision of vaccine or antivirals to homebound patients and family members. After all, home care is their area of expertise! Unfortunately, current regulations tightly control patient eligibility for home care and hospice. Unless these regulations are officially relaxed during pandemic, we may waste this valuable home care resource.

Photo by MIKI Yoshihito

In pandemic, everyone wants a vaccine as soon as they become available (in contrast to seasonal influenza, where we struggle to reach even 50% vaccination rates). Since many pharmacies have now stepped into the role of routine vaccine providers, hopefully they also have plans for an onrush in pandemic. Widespread prescriptions for prophylactic antiviral treatment may also add to pharmacy surge.

Nursing homes, assisted living facilities, and adult foster care will face increased demand for urgent admissions, both from the hospital and for homebound patients who lose caregiving support due to illness. In addition, facility residents may suffer increased illness and death. Considering the close relationships between many facility caregivers and their patients, the emotional as well as physical burden on facility workers will be high. Even health insurers will find themselves under attack in pandemic from a rapid increase in health care utilization and billing. Are insurer financial reserves ready for this?

Let’s Just Work Harder – Or Not!

OK – we all get it. There will be a lot more patients in a pandemic surge. So why can’t we handle pandemic surge by just knuckling down and working longer and harder? After all, that’s what health care does in many other surge situations! Unfortunately, I haven’t talked yet about the effects of pandemic on work force, where it really gets scary.

When it comes to pandemic influenza, it’s often healthy adults (the primary workforce) and children who sicken, unlike seasonal flu which disproportionately affects the elderly, very young, and medically frail. 15-35% of the population are expected to develop clinical illness during a pandemic. When people get sick, they don’t work. Skyrocketing employee absence will result from a combination of personal illness, caring for family members, increased childcare demands (particularly if schools close), and even fear of exposure.

Photo by Matteo Bagnoli.

Experts suggest anywhere from 0.83-2.4 work days will be lost per employee over the 4-12 weeks of a pandemic wave. This represents at least a 4-10% drop in the workforce at the same time that outpatient visits may increase by over 20%! What if one of those absences is a key employee – like one of two physicians? Martyrdom (working while ill) cannot be allowed during a pandemic, no matter how high the demand – it just makes things worse by exposing more employees and patients to illness. Work force absence also affects vendors and deliveries – a real problem with the current healthcare trend for limited on-site supplies and medications.

Pandemic – a Bell-Shaped Curve

One more doom and gloom fact. My number games assume a nice even spread of demand over the 4-12 weeks of a pandemic wave. Unfortunately, pandemics happen in a bell-shaped curve, meaning the bulk of deaths, patient visits, and workforce absences actually cluster in the middle. During those few weeks, the numbers may actually be worse than I’ve stated (but the beginning and the end of the wave will be better). It’s clear that working harder and longer will not get us through the medical surge problems of a pandemic.

We Need Pandemic Plans

Image by Greg McMullen

Have I convinced you of the need for pandemic plans? If you are in the healthcare field, there is no way to avoid the impact. Patient needs will increase by 5-25% with 4-10% fewer workers available to provide care. Infection control procedures must be instituted in every setting. Equipment, medication, and supply shortages are likely (in H1N1, we ran out of personal protective equipment like masks). On top of this, we’ll all be learning as we go. Federal, state, and local health authorities issue frequently changing recommendations based on the most recent information and research – it would be nice if they all agreed, but clearly that was not the case in H1N1. What will be your process for staying on top of the latest information regarding testing, treatment, and policies?

A Ray of Hope

Information and ideas on pandemic planning are easily found. I’ll include links to a few of my favorites below. However, implementation requires leadership, organization, time and money. I’m an optimist, but I think I can make a sizable dent in this problem for my community if everyone works on it together – including public health and volunteer programs such as the Medical Reserve Corps. Check back for updates to see if I am successful! In the meantime…

P.S. Yes, I’m still alive and blogging. I’m actually on a road trip for 2 weeks. Everyone knows what life is like the week before you go on vacation – there is no possible way to get everything done (including a blog post). But today is a rest day from travel, and in my perverted mind, that means thinking about emergency preparedness again!

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I’m trying to get prepared for the fall. What I want to know is how can I get antivirals to stock. Can those be ordered through a veterinary supply store like antibiotics? My fear is that if MERS or H5N7 raise their ugly heads here, there will be no way to get antivirals for my family. I understand that antivirals may not work against these viruses but I would still like to be prepared. Any suggestions would be greatly appreciated.

Stockpiling of antivirals is a concern for both citizens and the government. It is a balance between effectiveness, cost, and the risk of developing viral resistance if antivirals are overused.

Influenza is now completely resistant to the older, and far cheaper, adamantane class of antivirals (such as amantadine). During flu outbreaks over the past decade, some strains of influenza also develop resistance to our newer neuraminidase inhibitor class of antivirals (such as Tamiflu = Oseltamivir), but this has not been a severe problem – yet! If these drugs are used more commonly, the risk of viral resistance could increase significantly. This newer class also costs about $10 a day.

From an effectiveness point of view, there is significant controversy (not helped by the drug manufacturer’s refusal to release their data for independent review). The strongest evidence shows that if antivirals are started within 2 days of exposure, symptoms of illness will last one day less on average (you still get sick, but not for as long). There is weaker evidence suggesting antivirals decrease deaths and severe complications in the most vulnerable patients (elderly, frail, etc). The weakest evidence is for preventing infection. Antivirals only work while you take them. In order to prevent infection, you must continue them as long as potential exposure continues. That makes sense for a closed group of people, like giving antivirals to everyone in a nursing home when the first resident gets sick. It doesn’t work as well for the general population in a pandemic or flu season when ongoing exposure may last for weeks. If everyone took antivirals for 4-12 weeks, it would probably just increase the likelihood of resistance!

My personal recommendation is against citizens stockpiling antivirals. I don’t keep them in my emergency kit. Investing in a healthy supply of masks, gloves, disinfectants, and soap is a better use of funds. In order to get infected, you have to breath in the virus, or touch a surface with live virus and then touch your face. Learning and practicing good hygiene is a probably a better preventative than using antivirals. The exception may be if you are in a high complication risk group. If your physician feels your risk is significant, they could give you a prescription to fill in advance and have on hand. Realize you will need to redo this every year, because of drug expiration, and insurance may not pay for prophylactic prescriptions. I strongly advise against getting antivirals from another country or an unreliable source.

Maybe not the answer you wanted, but I believe it is the correct one.
Sheila

Thanks for a very informative answer. It makes sense and reassures me that I am on the right track as far as my supplies go. I have had my concerns about the effectiveness of antivirals but I had wanted to be sure that it wasn’t something I should have stocked. Thanks again for a very informative answer. I learn a lot on this site.

I think there are 2 other items that need to be addressed. First the pandemic will not hit all areas equally. Some ares might have a few (relative) and other areas might get well above the average. This will complicate the response and treatment as medicines and equipment may have to be moved to different facilities to react to the number of patients. The second item might be more troubling. That is the number of caregivers and medical professionals who, for a variety or reasons don’t get immunized against the potential pandemic. Sure some who get the immunization will get sick as nothing is 100%. It seems that there are some areas in the country will exacerbate the effects of a pandemic.

I agree completely. Regional pandemic variation is the rule, not the exception. For both natural and “man-made” reasons, not every neighborhood, city, county, state, or even country, will be hit equally. One of the most important parts of pandemic planning (or actually, planning for any disaster), is building relationships and agreements during “good times” in order to expedite sharing during “bad times”. Sharing includes supplies, meds, equipment, but also personnel and expertise. We also need to accept the basic concept of asking for help, something Americans can be reluctant to do.

For what it’s worth, immunization and treatment rates go up during pandemic compared to seasonal flu, particularly for caregivers and healthcare who see first hand how bad it is, but there will still be some that will not comply. This may be the same group that tries to keep working when sick! During pandemic, it is important to realize that treatment recommendations are for the good of society as well as the good of the individual. Effectiveness may not be 100% for any individual, but recommendations may still control overall spread. I think individual business/agency pandemic plans need to lay out expectations in advance, including plans for employees who will not follow official treatment recommendations – prohibit them from working, insist on mask and PPE use, avoid patient care, etc. Personally, I believe expectations of employees should be higher with stricter enforcement in times of disaster than in normal “flu”.
Sheila

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Sheila Sund, M.D.

I am a physician from Salem, Oregon with a disaster fixation. Having left my previous specialties of neurology and hospice behind for now, I am instead focused on emergency preparedness, particularly healthcare response. Somehow the powers that be frequently forget that physicians will be an essential part of any response and recovery. I stick my head in everywhere to make sure we are included, and in the meantime, learn a lot about emergency response in general.
By Sheila Sund
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